The first time I spoke with Gail Levine, an internist whose practice at Boston’s Brigham and Women’s Hospital is devoted to patients with severe mental illness, she said something that still nags at me. I was caring for a patient of hers, a man in his mid-50s who had paranoid schizophrenia. Mr. D. had recently had a large myocardial infarction but refused revascularization. Though his condition had stabilized, that day he’d become visibly dyspneic, with hemodynamic evidence of early tamponade. Because he’d repeatedly expressed his unwillingness to have needles stuck in him, I feared he would refuse pericardiocentesis and was relieved when Levine called.
My track record negotiating with patients with serious mental illness who refuse treatment wasn’t great. I’d recently cared for a relatively young woman with schizophrenia who had severe, symptomatic mitral regurgitation. She was an ideal surgical candidate, but I couldn’t convince her to get blood draws, much less surgery. She sat in bed, gently rocking, brushing her hair, not answering questions, and only occasionally allowing an exam. I soon gave up trying to persuade her and didn’t attempt to understand her reasoning. Instead, because she clearly lacked decision-making capacity, we initiated the months-long process of court-appointed guardianship. This step spared me a harder decision: Should we save her heart if doing so further harmed her already tortured soul?
With Mr. D., there was no time to punt the tough decisions to someone else; if he went into tamponade, he could die. Though I wouldn’t have let that happen, Levine wasn’t so sure. “You realize,” she said, “that patients with severe mental illness die, on average, at age 53. This is one big reason why. Doctors assume that because he has mental illness, he has no quality of life. You can’t just let him refuse.”